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Transcript of OVERVIEW DATA, GRAPHS AND TABLES UPDATED DECEMBER 2010 Indonesia’s Health Sector Review 1 Next...
OVERVIEW
DATA, GRAPHS AND TABLES
UPDATED DECEMBER 2010
Indonesia’s Health Sector Review
1
Next Update foreseen in March 2011 adding
the Actuarial Estimates and
Jamkesmas Review
Background2
The WB received requests for electronic copies of the various charts, tables and graphs included in the reports and papers produced for the Indonesia Health Sector Review
In response, this synthesis report has been created. It includes the key charts, tables and graphs that can be downloaded
This is a living document and updates will be inserted when new data become available
This document does not summarize all the work that was carried out, rather it includes mainly the data and graphs. For summaries and details please refer to the documents listed in the annex. Each slide includes the source document for easy reference
This review was put together by the World Bank Jakarta-based health team including Claudia Rokx, Pandu Harimurti, Puti Marzoeki, Eko Pambudi, George Schieber, Ajay Tandon and John Giles. Elif Yavuz was involved in earlier versions.
I ndones i a ’ s hea l th sys tem per fo rmance i s cha l l enged by a chang ing env i ronment :Ongo ing demograph i c and ep idemio l og i ca l t r ans i t i ons tha t a re l i ke l y t o i ncrease demand and resu l t i n more cos t l y and more d i ve r se hea l th care .Add i t i ona l p ressure w i l l come f rom emerg ing d i seases and ep idemics such as HIV /A IDS, H5N1 (Av i an I nfl uenza ) and H1N1 (Sw ine I nfl uenza ) .The imp lementa t i on o f Law No. 40 /2004 on Un i ve r sa l Hea l th I nsurance Coverage (UHIC) w i l l f u r the r i ncrease demand and u t i l i za t i on .
3
Indonesia’s Dynamic Environment
Indonesia’s population is growing: by 2025 there will be 273 million people and the elderly population will almost double to 23 million.
4
0-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75+
-15,000 -10,000 -5,000 0 5,000 10,000 15,000
Population in Thousands 2000
0-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75+
-15,000 -10,000 -5,000 0 5,000 10,000 15,000
MalesFemales
Population In Thousands 2025
Source: BPS 2005.
The demographic transition may provide a ‘demographic bonus’ in the short term if those coming of working age are employed…
5
Source: Adioetomo 2007.
Dependency ratio, 1950-2050
0
10
20
30
40
50
60
70
80
90
1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050
year
rati
o t
o w
ork
ing
-ag
e p
op
ula
tion
young
eldery
window of opportunity
demographic bonus
total
…but may also have serious implications for the delivery and financing of health care; doubling the need for care from aging alone.
6
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
Although communicable disease remains a large burden, with the changing age structure disease patterns will shift to noncommunicable disease and injuries, increasing and diversifying the demand for health care further.
Perinatal / Maternal Communicable Disease
Non-communicable Disease
Injuries0
10
20
30
40
50
60
70
SKRT'95
SKRT'01
Riskesdas07
Source: Riskesdas Survey 2007.
7
Changes in Burden of Disease in Indonesia
The obesity rate is rising and increased prevalence of risk factors will change the burden of disease – increasing the need for preventive measures.
Male
Females
Urban
Rural
Poorest
Quintile 2
Quintile 3
Quintile 4
Richest
0 5 10 15 20 25 30 35
7.7
29
23.6
15.7
15
16.8
17.8
19.9
23.2
Adult Obesity in Indonesia (%)
Source: Riskesdas Survey 2007.
8
Increased need will demand more resources for health. Fortunately, despite the global economic crisis, the macroeconomic picture is still favorable.
World Bank. 2009. Giving More Weight to Health in Indonesia.
Pre-crisis forecast
Post-crisis forecast
45
67
8R
eal G
DP
gro
wth
rat
e
2003 2005 2007 2009 2011 2013year
Source : IMF
9
I ndones i a ’ s hea l th sys tem per fo rmance measured i n t e rms o f hea l th ou tcomes , fi nanc i a l p ro tec t i on , consumer awareness and equ i t y and eff i c i ency i s m ixed : I ndones i a scores h i gh l y on reduc ing ch i l d mor ta l i t y bu t l ow on reduc ing mate rna l mor ta l i t y.I nequ i t i e s i n hea l th ou tcomes be tween i ncome l eve l s and geograph i c a reas a re ve ry l a rge and cons t i tu te a ma jo r p rob l em fo r the hea l th sec to r overa l l .
10
Health System Performance
Indonesians live longer in 2010 and child mortality has fallen dramatically since the 1960s.
11
World Bank. 2008. Investing in Indonesia’s Health: Health Expenditure Review 2008.
Life expectancy
Infant mortality
Under-five mortality
050
100
150
200
Infa
nt/u
nder
five
mor
talit
y ra
te
4050
6070
Life
exp
ecta
ncy
1960 1970 1980 1990 2000 2010year
Source : WDI 2009
But geographic inequities remain large: life expectancy varies between 60 in West Nusa Tenggara and 75 in Yogyakarta.
12
World Bank. 2008. Investing in Indonesia’s Health: Health Expenditure Review 2008.
Indonesia performs well in terms of infant mortality relative to other comparable health spending level countries but less well for its income.
13
World Bank. 2009: Health Financing in Indonesia: A Reform Road Map.
China
IndiaLao PDR
Vietnam
Indonesia
Malaysia
Thailand
Bangladesh
Sri Lanka
Below average Above average
Bel
ow a
vera
geA
bove
ave
rage
Att
ainm
ent
rela
tive
to in
com
e
Attainment relative to health spending per capitaSource: WDI 2009, WHO 2008
INFANT MORTALITY (2008)
Despite significant reduction in IMR over time, some neighboring countries have performed better.
14
World Bank. 2009: Health Financing in Indonesia: A Reform Road Map.
Indonesia
China
Sri Lanka
Vietnam Thailand
India
525
100
250
Infa
nt m
orta
lity
1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010Year
Source: WDI 2009Note: y-axis log scale
Infant mortality, 1960-2009
And there are large inequalities between provinces and income levels.
15
0
20
40
60
80
100
120
DI Y
ogyakart
a
Centr
al J
ava
Centr
al K
alim
anta
n
DK
I Jakart
a
Bali
East K
alim
anta
n
Nort
h S
ula
wesi
East Java
DI A
ceh
Bangka B
elit
ung
Jam
bi
Ria
u
West Java
South
Sum
atr
a
South
Sula
wesi
Lam
pung
Bante
n
Ria
u Isla
nds
West K
alim
anta
n
West S
um
atr
a
South
-east S
ula
wesi
West P
apua
Papua
Bengkulu
Nort
h S
um
atr
a
Centr
al S
ula
wesi
Goro
nta
lo
Nort
h M
alu
ku
South
Kalim
anta
n
East N
usa T
enggara
West N
usa T
enggara
Malu
ku
West S
ula
wesi
Death
for
every
1000 liv
e b
irth
Infant Mortality Child Mortality
Source: DHS 2007.
In fact, some of Indonesia’s provinces are at par with some of the best and worst performing countries.
16
World Bank. 2009: Presentation on Health Financing in Indonesia: A Reform Road Map.
West Sulawesi
North Maluku
Riau IslandsWest Java
DKI Jakarta
West Nusa Tenggara
West SumatraSouth SumatraRiau
East KalimantanDI Yogyakarta
Bangladesh
Cambodia
Papua New Guinea
Uganda
Ukraine
Zimbabwe
China
Congo, Rep.
India
Niger
San Marino
Timor-Leste
Tanzania
Vietnam
050
100
150
Infa
nt m
orta
lity
per
1000
live
birt
h
Indonesia Other countries Source: IDHS (2007) & WDI 2009
Infant mortality, 2008
Indonesia also performs less well on maternal mortality for its income level in international comparisons.
17
World Bank. 2009: Health Financing in Indonesia: A Reform Road Map.
Bangladesh
China
India
Lao PDR
Sri LankaVietnam
Indonesia
MalaysiaThailand
Below average Above average
Bel
ow a
vera
geA
bove
ave
rage
Att
ainm
ent
rela
tive
to in
com
e
Attainment relative to health spending per capitaSource: WDI 2009 (MMR:Model WHO/UNICEF/UNFPA/The Worldbank), WHO 2008
MATERNAL MORTALITY, 2008
And will need extra efforts to achieve the MDG of reducing maternal deaths by 75 percent by 2015.
The World Bank 2010.”…End Then She Died”: Indonesia Maternal Health Assessment.
18
Underweight among children under five years of age has declined significantly…
19
1989 1992 1995 1998 1999 2000 2001 2002 2003 2004 2005 2007*0
5
10
15
20
25
30
35
40
6.3 7.211.6 10.5
8.1 7.5 6.3 8 8.3 8.6 8.85.4
31.2 28.3 2019
18.317.1 19.8
19.3 19.2 19.6 19.2
13
37.535.5
31.629.5
26.424.6
26.127.3 27.5 28.2 28
18.4
Moderate Severe
Underweight
Percentage
Source : Susenas 1989-2005, Riskesdas 2007
Source: Susenas various years.
…however, stunting rates, which are an indicator of chronic malnutrition, remain very high.
20
BangladeshChina
IndiaLao PDR
Sri Lanka
VietnamIndonesia
Thailand
Below average Above average
Belo
w a
vera
ge
Above
ave
rage
Att
ain
ment
rela
tive t
o in
com
e
Attainment relative to health spending per capitaSource: WDI 2009, WHO 2008
Stunting Among Children under 5 years old, 2000-2009
Health Spending Trends
BY ANY MEASURE INDONESIA’S PUBLIC SPENDING ON HEALTH IS LOW AND INEQUITABLY DISTRIBUTED:
INDONESIA’S PUBLIC HEALTH SPENDING AS A PROPORTION OF GDP HAS STAGNATED IN RECENT
YEARS AND COMPARES UNFAVORABLY WITH OTHER COMPARABLE INCOME COUNTRIES.
INDONESIA’S OUT-OF-POCKET (OOP) SPENDING IS ABOUT AVERAGE FOR ITS INCOME LEVEL AND HAS
IMPROVED IN RECENT YEARS.INDONESIA DOES REASONABLY WELL ON REDUCING
CATASTROPHIC SPENDING INCIDENCE BUT LESS WELL ON HEALTH INSURANCE COVERAGE AND EQUITY.PUBLIC SPENDING ON HEALTH IS INEQUITABLY DISTRIBUTED ACROSS PROVINCES AND INCOME
QUINTILES.
21
Despite substantial increases in government health expenditures as a share of GDP over recent years, Indonesian governments barely spends 1 percent of GDP on health.
2001 2002 2003 2004 2005 2006 2007* 2008* 2009**0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
45,000
0.0%
0.2%
0.4%
0.6%
0.8%
1.0%
1.2%
Central Province District Series4 Share of GDP
22
Government health expenditures by level of government (2001-2009)
World Bank. 2008. Investing in Indonesia’s Health: Health Public Expenditure Review 2008.
Total and public health spending in Indonesia is low relative to other comparable income countries.
23
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
China
Cambodia
Lao PDR MalaysiaThailand
Vietnam
Samoa
Indonesia
05
1015
Tot
al H
ealth
Spe
ndin
g (%
GD
P)
100 250 1000 10000 25000GDP per capita
Source: World Development Indicators 2009, WHO 2008Note: GDP per capita in current US$; Log scale
TOTAL HEALTH SPENDING VS INCOME, 2008
ChinaCambodia
Lao PDR
Malaysia
ThailandVietnam
Samoa
Indonesia
05
1015
Gov
ernm
ent
Hea
lth S
pend
ing
(% G
DP
)
10 100 250 1000 10000 25000GDP per capita
Source: World Development Indicators 2009, WHO 2008Note: GDP per capita in current US$; Log scale
GOVERNMENT HEALTH SPENDING VS INCOME,2008
And government health spending as a share of the budget is even lower than total government expenditures as a share of GDP.
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
Indonesia
Indonesia
10
20
30
4050
Govern
ment
spendin
g (
% G
DP
)G
overn
ment
health s
pendin
g (
% b
udget)
100 250 1000 2500 10000 25000GNI per capita (US$)
Source: WDI
Government spending vs income, 2004-2006
Government spending (% GDP)
Government health spending (% budget)
24
OOP spending, a measure of financial protection, is about average relative to comparators.
25
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
China
Lao PDR
Malaysia
Philippines
Thailand
Samoa
Indonesia
Cambodia
Vietnam
020
4060
80
Out
-of-
pock
et h
ealth
spe
ndin
g(%
tot
al h
ealth
spe
ndin
g)
100 250 1000 10000 25000GDP per capita, current US$
Source: World Development Indicators 2009, WHO 2008Note: GDP per capita in current US$; Log scale
OOP spending as share of total health spendingvs Income per capita, 2008
Financial protection, measured as the OOP share of nonfood spending has improved.
Source: Equitap Update 2009.
26
27
Malaysia (1999)
Taiwan (2000)
Indonesia (2006)
Thailand (2002)
Hong Kong (2000)
Sri Lanka (1997)
Philippines (1999)
Indonesia (2001)
Korea (2000)
Nepal (1996)
India (2000) China (2000) Bangladesh (2000)
Vietnam (1998)
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
Greater than 25 percent of nonfood expenditures Greater than 10 percent of total expenditures
% o
f h
ou
se
ho
lds e
xce
ed
ing
th
resh
old
Catastrophic payments for health care are defined as OOP payments in excess of a substantial proportion of the household budget, usually 10-40 percent (Van Doorslaer et al. 2006; Xu et al, 2003)
By regional standards, the incidence of catastrophic health spending is low in Indonesia.
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
Equity of public spending on health could be improved; it is low in international comparisons and has not changed much since 2001.
28
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Shanxi province (C
hina) 2003
Heilongjiang (C
hina) 2003
Zhejiang (C
hina) 2003
Gansu (C
hina) 2003
Indonesia 2001
Indonesia 2006
India 1996
Mongolia*
Bangladesh 2000
Vietnam
2003
Malaysia 1996
Thailand 2002
Sri L
anka 2004
Hong K
ong 2002P
oore
st q
uin
tile
sh
are
of s
ub
sid
y
Poorest Quintile Share of Public Hospital Inpatient Subsidies in EAP Region
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
Inequities between provinces are also evident from differences in health expenditures.
29
World Bank. 2008. Investing in Indonesia’s Health: Health Expenditure Review 2008.
District Public Health Expenditures by Province (2005)
Technical efficiency is low in Indonesia in global comparisons and there are large differences between provinces.
30
AusA
B
C
Cdn
CN
CZ
F
D
G
HKHIdn
Irl
I
JRok
LMys
M
MngNl
N
PS
ECh
Tw
T
Tk
UK
US
V
averagecase-flow
averagebed occupancy
0
20
40
60
80
100
0 10 20 30 40 50 60 70 80 90 100
percent bed occupancy rate
case
-flow
(cas
es pe
r bed
per y
ear)
A: high case-flow low occupancy
C: high case-flow high occupancy
B: low case-flow low occupancy
D: low case-flow high occupancy
N A D
Sumut
Sumbar R i a u
J a m b i
Sumsel Bengkulu Lampung
Bangka Belitung DKI Jakarta
JabarJatengDIYJatim
Banten
B a l iNTB
NTT
KalBarKalseng
Kaltim
Sulut
SultengSulselSulteng Irian Jaya Tengah
Irian Jaya Timur
average case-flow
average bed occupancy
Kalteng
Maluku
Irian Jaya Barat
0
20
40
60
80
100
0 10 20 30 40 50 60 70 80 90 100
percent bed occupancy rateca
se-fl
ow (c
ase
per b
ed p
er y
ear)
A: high case-flow low occupancy
C: high case-flow high occupancy
B: low case-flow low occupancy
D: low case-flow high occupancy
Technical efficiency is ideally measured using case-mix unit cost data, however these are not available in Indonesia. Instead case-flow and average bed occupancy are used.
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
An a l ready s t re tched hea l th sys tem w i l l i ncur fu r ther p ressure due to i ncreased demand f rom ongo ing demograph i c , nu t r i t i on and ep idemio l og i ca l t r ans i t i ons as we l l a s the i n t roduc t i on o f un i ve r sa l hea l th i n surance coverage .I ndones i a ’ s hea l th i n f ras t ruc tu re , a l though w ide l y ava i l ab l e f o r p r imary care , does no t have suff i c i en t beds o r hea l th worker s to r e spond to these i ncreased needs .Pharmaceu t i ca l supp l i e s a re r easonab le bu t mos t I ndones i an pay more than they need to and mos t expend i tu res a re ou t o f pocke t .There i s a p ress ing need to address human resources d i s t r i bu t i on i nequ i t i e s and qua l i t y. Sat i s fac t i on l eve l s ove ra l l a re good a l though the re i s a h igh l eve l o f d i s sa t i s f ac t i on w i th var i ous aspec t s o f hea l th care .
31
Indonesia’s Health Delivery System
Indonesia’s primary public health care system is extensive: more than 90 percent of the population has access to primary care facilities.
Source: MoH. 2008. Health Profile.
32
Ratio Puskesmas per 100,000 Population
While Indonesia has a well-developed primary health system, it has fewer hospital beds than comparators.
33
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
China
Cambodia
Lao PDRMalaysia
Philippines
ThailandVietnam
SamoaIndonesia
05
1015
Hos
pita
l Bed
s pe
r 1,
000
100 250 1000 10000 25000GDP per capita, current US$
Source: World Development Indicators 2009, WHO 2008Note: GDP per capita in current US$; Log scale
HOSPITAL BED SUPPLY VS INCOME, 2000-2010
And Also Fewer Health Workers 34
World Bank. 2010. New Insights into the Provision of Health Services in Indonesia: A Health Work Force Study.
China
CambodiaLao PDR
MalaysiaPhilippines
ThailandVietnam
SamoaIndonesia02
46
8D
octo
r per
1,0
00
100 250 1000 10000 25000GDP per capita, current US$
Source: World Development Indicators 2009, WHO 2008Note: GDP per capita in current US$; Log scale
DOCTOR SUPPLY VS INCOME, 2000-2010
CambodiaLao PDRMalaysia
Philippines
ThailandVietnam
SamoaIndonesia
05
1015
20M
idw
ives
/Nur
ses
per 1
,000
100 250 1000 10000 25000GDP per capita, current US$
Source: World Development Indicators 2009, WHO 2008Note: GDP per capita in current US$; Log scale
MIDWIVEs/NURSES SUPPLY VS INCOME, 2000-2010
At the Puskesmas level most basic services are available.
35
Quality Measures Public Settings Private SettingsPuskesmas Pustu Private
NursePrivate
MidwifePrivate
MDsAll
Settings
Structural qualityInternal water source (%) 89 71 80 84 89 84
Inpatient beds (%) 28 3 3 28 3 18Functioning microscope (%) 79 5 1 3 7 25
Tuberculosis service (%) 95 30 8 2 44 38Measles vaccines in stock (%) 97 51 5 48 11 51
Tetanus toxoid vaccine in stock (%)
97 55 9 59 12 55
Hepatitis B vaccine in stock (%) 92 52 6 54 16 52
Structural Indicators and Quality Scores for Prenatal, Child Curative and Adult Curative Care (by Clinical Setting)(2007)
World Bank. 2010. New Insights into the Provision of Health Services in Indonesia: A Health Work Force Study.
Secondary and tertiary care have not progressed equally: the number of hospitals and hospital beds has grown slowly.
1995 1997 2000 2003 2005 20060
20000
40000
60000
80000
100000
120000
140000
MoH Province, district, municipal Armed forces, policeState-owned Private
Increase in numbers of hospital beds between 1995 and 2006 by ownership
36
World Bank. 2008. Investing in Indonesia’s Health: Health Expenditure Review 2008.
There are 2.5 beds per 10,000, 3.5 Puskesmas per 100,000 and 5.6 hospitals per 1,000,000 Indonesians, however, on average, there are serious inequities among provinces.
37
World Bank. 2008. Investing in Indonesia’s Health: Health Expenditure Review 2008.
We
st P
ap
ua
No
rth
Su
law
esi
Ma
luku
Pa
pu
a
Ba
li
Ea
st K
alim
an
tan
We
st S
um
atr
a
D I
Yo
gya
kart
a
DK
I Ja
kart
a
Go
ron
talo
No
rth
Ma
luku
Na
ng
gro
e A
ceh
Da
russ
ala
m
So
uth
Su
law
esi
So
uth
Ka
lima
nta
n
Ce
ntr
al S
ula
we
si
Ce
ntr
al K
alim
an
tan
Ea
st N
usa
Te
ng
ga
ra
Be
ng
kulu
We
st K
alim
an
tan
Ba
ng
ka B
elit
un
g Is
lan
d
Jam
bi
Ce
ntr
al J
ava
No
rth
Su
ma
tra
So
uth
Ea
st S
ula
we
si
So
uth
Su
ma
tra
Ria
u
Ea
st J
ava
We
st N
usa
Te
ng
ga
ra
La
mp
un
g
We
st J
ava
Ba
nte
n
Ind
on
esi
a
0
200
400
600
800
1,000
1,200
0
2
4
6
8
10
Health Center Ratio bed per 10,000 Health center ratio per 100,000
# H
ealt
h c
ente
r
Rati
o
The ratio of physicians to population also masks significant inequities among urban and rural areas.
Source: KKI 2008.
38
DPT3 immunization, often considered a good indicator of health system coverage, is low for Indonesia’s health expenditure level and may indicate low levels of efficiency.
Country Total health expenditure pc (US$)
DPT3 immunization coverage
Indonesia 26 70
Uganda 22 84
Rwanda 19 95
Tajikistan 18 85
Tanzania 17 90
Nepal 16 75
Pakistan 15 80
Bangladesh 12 88
39
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
Analysis of the number of staff per primary care facility illustrates inequalities at the facility level…
Facility
National
Java-Bali
Sumatra
Other Provinces
1997 2007 1997 2007 1997 2007 1997 2007
Puskesmas
Number of Doctors 1.51 1.90 1.68 1.96 1.19 1.85 1.09 1.62
Number of Doctors (%) 3.4 7.0 1.5 5.9 2.0 6.8 15.9 11.3
Number of Midwives 5.85 3.69 5.76 3.44 6.33 5.28 5.62 3.18
Number of Nurses 5.05 6.14 4.58 5.60 6.16 7.16 5.84 7.61
Pustu
Number of Midwives 0.98 0.81 1.06 0.76 1.13 1.17 0.44 0.21
Number of Nurses 1.08 1.06 1.02 1.09 1.16 1.08 1.16 0.89
Source: IFLS 1997; 2007.
40
…and quality, measured as diagnostic and treatment ability, varies between regions and geographic areas and has not improved much over time.
41
Service
National Java/Bali Sumatra Other Provinces
1997 2007 P= 1997 2007 P= 1997 2007 P= 1997 2007 P=
Prenatal Care
Public 42 46 *** 45 47 ** 35 39 ** 38 49 ***
Private 40 44 *** 43 46 *** 34 37 ** 39 46 ***Child Curative Care
Public 56 64 *** 58 66 *** 48 56 *** 55 65 ***
Private 55 59 *** 57 62 *** 50 52 54 60 ***
Adult Curative Care
Public 49 56 *** 52 59 *** 43 48 *** 44 53 ***
Private 46 53 *** 48 56 *** 40 51 *** 44 51 ***
Quality of Public Health Services in Indonesia 1997-2007 (by Region)
*** p<0.01, **p<0.05
World Bank. 2010. New Insights into the Provision of Health Services in Indonesia: A Health Work Force Study.
In international comparisons Indonesia spends little on medicine per capita, and most expenses are out-of-pocket.
India
Indonesia
Cambodia
Philippines
Vietnam
Malaysia
Thailand
0 5 10 15 20 25
GovernmentPrivate
Source: WHO. 2004. The World Medicines Situation.
42
Over half of Indonesian districts spent less than US$0.55 per capita in 2007 and some spent less than US$0.10. Districts would need to spend around US$1.50 per capita or more on average (assuming the central government continues to provide around US$0.55 per capita for Puskesmas drugs) to provide all the primary care medicines recommended by WHO.
Spending on drugs per capita in US$
But most Indonesians pay more than they need to for their medicines when they buy from the private sector or from public hospitals.
Price ratio to median international indicator price
Originator brands Most sold branded generic
Lowest price generic
Private pharmacies 22-26 6-7 2.6
Public hospitals 22 1.7-6 2.15
Source: National Institute for Health Research and Development (NIHRD) Survey 2004.
43
Provision of health services by private health providers has grown significantly over the past decade.
At the national level, physician practices per 1,000 of population grew at 38.5 percent
The number of midwife practices per 1,000 population increased by 4.64 percent.
And the majority of physicians working in aPuskesmas supplementtheir income throughprivate service provision
World Bank. 2010. New Insights into the Provision of Health Services in Indonesia: A Health Work Force Study.
44
And utilization of private health providers fell after Askeskin was introduced and the utilization of Puskesmas increased.
45
Changes in choice between public and private sector between 1999 and 2008
World Bank. 2009. Doctors, Midwives and Nurses: Health Work Force Review.
However, most Indonesians continue to seek ambulatory care from private providers when ill.
Publ
ic H
osp
Pusk
es/ P
ustu
Privat
e Hos
pita
l
Privat
e Clin
ic
Privat
e ph
ysicia
n
Nur
se, M
idwife
Trad
. Pra
ct.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
20071997
Source: IFLS 1997 & 2007.
46
Overall consumer satisfaction with inpatient and outpatient services appears good…
47
58.1
65.2
59.7
32.2 31.3 32.3
7.7
3.37.2
1.2 0.2 0.90.9 0.0 0.00
10
20
30
40
50
60
70
GDS2 (N=7.916) Susenas-Inpatient (N=19.294) Susenas-Outpatient (N=2.657)
Satisfied Somewhat satisfied Somewhat unsatisfied Unsatisfied No response
Source: GSD2 and Susenas.
…although there is a high level of dissatisfaction with various aspects of the provision of health care…
family visit
cleanliness
freedom of choice
private consultation
involvement in Decision making
information availability
hospitality
waiting time
0 5 10 15 20 25 30 35
11.6
21.7
27.9
25.6
29.7
24.2
17.2
21.7
18.3
26.8
27.3
32.8
24.1
13.6
26.1
inpatient outpatient
percent
Source: Sakernas National Health Survey 2004.
48
Dissatisfaction With Various Aspects of Health Services (%)
…and many people continue to opt for self-treatment or forego treatment altogether.
49
Source: Susenas various years.
The new government i s commi t ted to imp lement ing the re fo rm and assur ing a l l I ndones i an c i t i zens access to qua l i t y hea l th se rv i ces and fi nanc i a l p ro tec t i on aga ins t the impover i sh ing eff ec t s o f l a rge unpred i c tab l e med i ca l care cos t s .Fu lfi l l i ng th i s commi tment w i l l r equ i re the deve l opment , imp lementa t i on , and mon i to r ing o f po l i c i e s aff ec t i ng a l l a spec t s o f the hea l th sys tem – bas i c pub l i c hea l th p rograms ; de l i ve ry sys tems and l og i s t i ca l capac i t y ; qua l i t y and d i s t r i bu t i on ; o rgan i za t i on , management , and accoun tab i l i t y ; pharmaceu t i ca l s ; fi nanc i ng ; pub l i c—pr i va te par tner sh ips and a l l l e ve l s o f government .
50
Health Financing Reform
Background51
The 2004 Social Security legislation (Law No. 40) envisages coverage of the entire population through a mandatory health insurance system evolving from the existing insurance programs.
As of 2009 the government has covered some 76 million poor and near poor through the Jamkesmas program, funded through the central government budget.
However, progress over the last five years has been slow in developing the final configuration of the health insurance system and the transition plan to provide health insurance to the remaining 50+ percent of the population who currently lack coverage remains to be developed.
Many local governments have developed their own financing schemes, some for the uncovered non-poor.
The health insurance reform is complicated by the big bang decentralization reform that took place in 2001 which transferred most of the authority and responsibility for assuring service delivery capacity to local governments.
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
Health insurance systems in Indonesia since 2008.
Current Insurance Systems
Ministry of Labor
Ministry of Finance
Ministry of Health
Ministry of Defense
JamsostekPrivate
insuranceAskes, HMOs
Military personnel
Social security Social HMO
Commercial health
insurance
PT Askes:- Civil servants- Commercial
HMOs
Jamkesmas (scheme for the poor)
Types:
Coverage (millions
of people)
Free health services
Technical oversightFinancial oversight
4.1
6.6. including personal accident
Civil servant: 14Commercial HMOs:
2276.4
Source: Gotama and Pardede. 2007. Adapted and updated by World Bank staff.
52
The Current Health Policy Baseline for Health Financing Reform: System Strengths.
53
The country has favorable demographic circumstances with dependency ratios falling over the next 30 years
There are high educational and literacy levels The government is committed to reform Health spending levels are not excessive The country achieves reasonable health outcomes, financial
protection and consumer satisfaction There is substantial experience with health insurance programs There is an extensive primary care delivery system Pharmaceuticals are generally available
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
54
Half the population lacks health insurance coverage Health financing and delivery systems are highly fragmented Human and physical infrastructures are limited and face quality and
efficiency problems Salary and capital subsidies to public health providers preclude the
development of a ‘level playing field’ for both public and private providers to compete on the basis of price
Critical data for decision making are lacking, including national and subnational health accounts, detailed information on the numbers, risk profiles of the insured and the uninsured, and unit cost information
Design features of the Jamsostek and Askes programs result in high OOP costs for program beneficiaries and limit operational effectiveness and sustainability
Local contributions vary widely, current intergovernmental fiscal redistributions may not adequately reflect local fiscal capacity and need, and the fiscal capacity of districts vary widely.
The Current Health Policy Baseline for Health Financing Reform: System Challenges.
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
55
Framework to Assess HI Financing Options.
What is the ‘ultimate’ HI system of Universal Coverage (UC) under Law No. 40: single unitary Social Health Insurance (SHI); or multiple systems under a single set of rules; or a unitary general revenue funded system (e.g., Jamkesmas for
all)? What are the specific details of this system with respect to:
single or multiple funds; eligibility of different groups including informal sector workers; benefits covered including cost sharing and referral
requirements; financing including public subsidies and regional contributions; provider payment and cost containment; quality assurance; Administration; and the role of the private sector.
What are the transition policies to get to (UC)?
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
56
Future Vision 1: Jamkesmas for All: An Indonesian NHS.
This approach approximates a National Health Service like that in Sri Lanka.
It reflects the fact that more than half of the population is currently poor or near poor, and thus has a very limited ability to pay.
It also recognizes the inherent difficulty of identifying the 61 percent of workers who are in the informal sector and having them pay premiums.
By picking up formal sector workers through general revenues, firms might be more competitive as their 3-6 percent payroll contributions would be eliminated and/or could be replaced by more efficient and equitable broad-based taxes.
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
57
Future Vision 2: A Single Integrated SHI Fund.
This approach approximates the ‘new’ national SHI model (now called Mandatory Health Insurance (MHI)) where the SHI is funded through both wage-based contributions for public and private sector workers (and retirees) and government general revenue contributions for the poor and other disadvantaged groups.
Under this approach there would be a single standardized national HI fund (although one could also establish multiple funds as in Germany or Japan).
The poor would be financed through the GoI budget, while government and private sector workers would be funded as now through wage-based contributions.
The GoI would need to decide if informal sector workers would be covered by the GoI like the poor (as in Thailand) or whether mechanisms can be developed to make them contribute some share of their earnings.
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
58
Future Vision 3: MHI through a Single Set of Rules Applying to Multiple SHI and NHS Type Programs.
This approach could be considered as a variant of Option 2 or a combination of Options 1 and 2.
Existing programs would be scaled up to include the entire population.
All the poor and other disadvantaged groups would be covered through Jamkesmas.
All private sector workers would be covered through Jamsostek (possibly though elimination of the opt out, employer size, and wage ceiling restrictions and adding requirements to cover retirees).
Civil servants and civil service retirees would be covered through Askes (or the Askes program could be folded into Jamsostek, or conversely).
A decision would need to be made about how to handle informal sector workers.
The three programs would have separate administrative structures but would operate under the same set of rules concerning issues such as benefits and contracting/provider payment.
There might be cross-subsidies required across programs on the financing side.World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
59
No Matter Which Option is Chosen, The Devil Will Be in The Detail.
Administrative and governance arrangements Defining the benefit package Determining eligible groups Determining purchasing/contracting arrangements and cost
containment policies Estimating actuarially sound premium levels Determining financing sources Defining revenue collection mechanisms Defining transition steps to new system Developing and implementing monitoring and evaluation
procedures
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
T h e p u r pos e o f t h e a c tu a r i a l e s t i ma te s wa s t o r e s pon d t o th e G o I r e qu es t t o a s s i s t i n d e ve l op i n g b a s e l i n e e s t i ma t e s f o r t h e c os t o f e x i s t i n g h e a l t h i n s u r a n c e p r ogr a ms a n d t o pe r f o rm a n a c tu a r i a l a n a l y s i s t o c os t d i ff e re n t op t i on s f o r a t t a i n i n g U HIC.
I t de mon s t r a te s th e i mpor ta n c e o f t h e de c i s i on s t o b e t a k e n re g a rd i n g th e d e ta i l a s e a c h de c i s i on i n fl u e n c es th e l e ve l o f fi n a n c i n g n e e de d .
T h e e xe r c i s e i n c l u de d th e d e ve l opme n t o f a ba s e l i n e ba s e d on t h e 2 0 0 8 A s k e s c l a i ms d a ta , t h e c re a t i on o f a r a n g e o f b a s e l i n es a n d t h e c re a t i on o f va r i ou s s c e n a r i o s .
60
Actuary Estimates Update in March 2011
I n a l l l i k e l i h o o d , a n d f o r a v a r i e t y o f r e a s o n s , I n d o n e s i a w i l l n e e d t o b o o s t h e a l t h s p e n d i n g i n t h e n e a r f u t u r e a s i t e x p a n d s a c c e s s t o c a r e t h r o u g h t h e e x p a n s i o n o f J a m k e s m a s , t h e h e a l t h i n s u r a n c e s c h e m e f o r t h e p o o r a n d t h e n e a r p o o r.
I n a d d i t i o n , p r o j e c t i o n s b a s e d o n d e m o g r a p h i c a n d e p i d e m i o l o g i c a l c h a n g e s i n t h e c o u n t r y i n d i c a t e t h e r e i s l i k e l y t o b e a s i g n i fi c a n t i n c r e a s e i n t h e d e m a n d a n d n e e d f o r h e a l t h s e r v i c e s a n d m o r e s o p h i s t i c a t e d c a r e .
D e s p i t e a t r i p l i n g o f t h e p u b l i c b u d g e t f o r h e a l t h o v e r t h e p a s t fi v e y e a r s , t h i s i n c r e a s e d n e e d , c o m b i n e d w i t h t h e f a c t t h a t I n d o n e s i a r e m a i n s a c o m p a r a t i v e l y l o w s p e n d e r o n h e a l t h , i n d i c a t e s t h a t t h e r e w i l l c o n t i n u e t o b e u p w a r d p r e s s u r e o n r e s o u r c e s f o r t h e h e a l t h s e c t o r i n t h e n e a r f u t u r e .
61
More Resources for Health; Assessing Fiscal Space
Visualizing fiscal space for Indonesia: different means by which government spending on health can increase.
World Bank. 2009. Giving More Weight to Health: Assessing Fiscal Space for Health in Indonesia.
62
Conducive macroeconomic conditions
Reprioritization
Sector-specific foreign aidOther sector-specific resources
Efficiency
1
2
3
4
5
6
7
8
Fiscal space for health(increase as % of government health spending)
One of the most important determinants of fiscal space for health is economic growth which has a positive outlook in Indonesia.
63
Pre-crisis forecast
Post-crisis forecast
45
67
8
Rea
l G
DP
gro
wth
ra
te
2003 2005 2007 2009 2011 2013Year
Source: IMF
Since the outbreak of the crisis, the IMF has lowered its growth and inflation forecasts for the country, although growth remains in the 6-7 percent range per annum over the period 2008-2013.
World Bank. 2009. Giving More Weight to Health: Assessing Fiscal Space for Health in Indonesia.
Higher revenues provide extra resources, but Indonesia’s revenues as a percentage of GDP (19 percent) are low in comparison with other lower-middle-income countries.
Lower income
Middle income
Upper middle
Higher income
0 5 10 15 20 25 30 35 40
Revenue (% of GDP), 2003-2006
64
World Bank. 2009. Giving More Weight to Health: Assessing Fiscal Space for Health in Indonesia.
Given current low levels of spending for health compared to other sectors, a good case can be made for reprioritizing in favor of health.
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008*0%
1%
2%
3%
4%
5%
6%
7%
Agriculture
Education
Health
Govt Apparatus National Defense
Infrastructure
Subsidies
Interest payments
% o
f G
DP
With subsidies declining again (in 2009) there might be increased space for the
health sector
65
World Bank. 2009. Presentation on Giving More Weight to Health: Assessing Fiscal Space for Health in Indonesia.
Indonesia’s has not depended significantly on external resources for health in recent years.
1995 1997 1999 2001 2003 20050
2
4
6
8
10
12
External resources (% of total health spending)
Source: WHO.
66
In addition to increasing budgets for health, effective fiscal space may be generated by increasing the efficiency of spending.
Sri Lanka is often presented as an example of a country that has been able to attain excellent health outcomes with relatively low levels of resources, in part because of the underlying efficiency of its health system.
67
World Bank. 2009. Giving More Weight to Health: Assessing Fiscal Space for Health in Indonesia.
Indonesia
Sri Lanka
Above a
vera
ge
Belo
w a
vera
ge
Above average Below average-3-2
-10
12
3P
erf
orm
ance r
ela
tive t
o p
er
capita h
ealth s
pendin
g
-3 -2 -1 0 1 2 3Performance relative to income percapita
Under-five mortality
Indonesia
Sri Lanka
Above a
vera
ge
Belo
w a
vera
ge
Above average Below average-3-2
-10
12
3P
erf
orm
ance r
ela
tive t
o p
er
capita h
ealth s
pendin
g
-3 -2 -1 0 1 2 3Performance relative to income percapita
Maternal mortality
Source: WDI 2009
Performance relative to income and health spending, 2008
Local variation in performance across districts further indicates potential efficiency gains.
Kab. Tana Toraja
Kab. Ciamis
Kab. Morowali
Kab. Subang
Kab. Parigi Moutong
Kab. Bombana
Kab. Pakpak Bharat
Kab. Madiun
Kota Ambon
Kab. Lombok Barat
Kab. Asmat
Kota Singkawang
Kab. Bangka Tengah
Bangladesh
Japan
Nepal
Papua New Guinea
Somalia
Timor-Leste
Indonesia
India
Niger
Pakistan
Chad
Turkey
Uganda
Vietnam
020
40
60
80
100
DP
T3 im
muniz
ation
Indonesia Other countries
DPT3 immunizationKota Padang Panjang
Kab. Kediri
Kab. Bantul
Kab. Barito Selatan
Kab. Hulu Sungai Utara
Kab. Nias Selatan
Kab. Yahukimo
Kota Kediri
Kab. Semarang
Kab. Kuningan
Kab. Barru
Kab. Purbalingga
Kab. Wonosobo Burundi
Bangladesh
Pakistan
Senegal
Ukraine
Bhutan
China
Ethiopia
Indonesia
CambodiaTanzania
020
40
60
80
100
Skille
d b
irth
attendance
Indonesia Other countries
Skilled birth attendance
Source: SUSENAS & WDI
Global comparison of Indonesian districts, 2005
Kab. Tana Toraja
Kab. Ciamis
Kab. Morowali
Kab. Subang
Kab. Parigi Moutong
Kab. Bombana
Kab. Pakpak Bharat
Kab. Madiun
Kota Ambon
Kab. Lombok Barat
Kab. Asmat
Kota Singkawang
Kab. Bangka Tengah
Bangladesh
Japan
Nepal
Papua New Guinea
Somalia
Timor-Leste
Indonesia
India
Niger
Pakistan
Chad
Turkey
Uganda
Vietnam
020
40
60
80
100
DP
T3 im
muniz
ation
Indonesia Other countries
DPT3 immunizationKota Padang Panjang
Kab. Kediri
Kab. Bantul
Kab. Barito Selatan
Kab. Hulu Sungai Utara
Kab. Nias Selatan
Kab. Yahukimo
Kota Kediri
Kab. Semarang
Kab. Kuningan
Kab. Barru
Kab. Purbalingga
Kab. Wonosobo Burundi
Bangladesh
Pakistan
Senegal
Ukraine
Bhutan
China
Ethiopia
Indonesia
CambodiaTanzania
020
40
60
80
100
Skille
d b
irth
attendance
Indonesia Other countries
Skilled birth attendance
Source: SUSENAS & WDI
Global comparison of Indonesian districts, 2005
Source: Susenas and WDI.
68
At l eas t 10 ,000 women con t inue to d i e o f ch i l db i r th -re l a ted causes every year i n Indones i a . Even though sk i l l ed b i r th a t tendance has i ncreased s i gn ifi can t l y, more needs to be done to acce l e ra te a r educ t i on i n dea ths and ach i eve MDG5 .A l a rge number o f women con t inue to de l i ve r a t home w i thou t p ro fe ss i ona l he lp . High l eve l s o f uncer ta in ty abou t med i ca l expenses con t i nue to de l ay the dec i s i on to seek care a t a f ac i l i t y. Even when women reach a f ac i l i t y on t ime , qua l i t y o f management i s poor and dea th ra te s a t f ac i l i t i e s r ema in h igh , e spec i a l l y, bu t no t on l y, i n poor a reas .
69
Focus on MDG 5: Reducing Maternal Death
There has been an impressive improvement in skilled birth attendance since 1987, but the poor continue to lag behind.
70
Disparities exist between province, economic quintiles, and education levels.
0
20
40
60
80
100
Mal
uku
Wes
t Sul
awes
i N
orth
Mal
uku
East
Nus
a Te
ngga
ra
Papu
a B
ante
n G
oron
talo
So
uthe
ast S
ulaw
esi
Wes
t Pap
ua
Sout
h Su
law
esi
Cent
ral S
ulaw
esi
Wes
t Kal
iman
tan
Wes
t Nus
a Te
ngga
ra
Sout
h Su
mat
ra
Cent
ral K
alim
anta
n W
est J
ava
Jam
bi
Lam
pung
B
engk
ulu
DI A
ceh
East
Kal
iman
tan
Sout
h K
alim
anta
n Ea
st Ja
va
Wes
t Sum
atra
B
angk
a B
elitu
ng
Cent
ral J
ava
Nor
th S
umat
ra
Ria
u N
orth
Sul
awes
i R
iau
Isla
nds
Bal
i D
I Yog
yaka
rta
DK
I Jak
arta
perc
enta
ge
Delivery assistant & place by province
% SBA % Facility base deliveryData source : IDHS 2007
71
Most poor women continue to deliver their babies at home with traditional birth attendants (TBAs) where the risk of maternal death is highest…
72
Poorest Poorer Middle Richer Richest0
102030405060708090
100
-
100
200
300
400
500
600
700
800
ANC/Prof del ANC/No prof del No care (No ANC/No prof del)No ANC/Prof del MMR
% A
NC
/Pro
fess
ion
al
deli
very
Mate
rnal
Death
per
100,0
00 L
ive B
irth
s
Source: DHS 2007.
…even though midwives are almost everywhere and are equally distributed.
Note: All types of midwives included. Source: Indonesia Health Profile 2008.
Government target is 100 midwives per 100,000 population by 2010.
73
Midwife availability has increased significantly, however, TBA remains the preferred choice of provider for childbirth.
World Bank. 2010. Presentation on “…and then she died..” Indonesia Maternal Health Assessment.
74
DIY
WJ
CJ
DKI
EJ
DKI
WJ
CJ
DIY
EJ
40
60
80
100
120
% D
eliv
ery
by h
ealth p
rofe
ssio
nal
20 40 60 80100Ratio midwife per 100000 pop
SBA VS Ratio midwife, 2007
DKI DIY
EJ
WJ
CJ
DKI
WJ
CJ
DIY
EJ
40
60
80
100
120
% D
eliv
ery
by h
ealth p
rofe
ssio
nal
200 400600Ratio TBA per 100000 pop
SBA VS Ratio TBA, 2007
Source: Skilled Birth Attendant (SBA) (IDHS, 2007), Ratio midwife (Indonesia health Profile, 2007)Ratio Traditional Birth Attendant (TBA) (PODES, 2008)Note Abbreviation: DKI=DKI Jakarta, WJ=West java, CJ=Central Java, DIY=Yogyakarta, EJ=East Java
There is a serious shortage of Ob-Gyns in Indonesia and the few there are cluster in richer urban areas.
75
Although more than 70 percent of pregnant women receive antenatal care by skilled providers, the quality of care varies widely.
76
World Bank. 2010. Presentation on “…and then she died..”. Indonesia Maternal Health Assessment.
Although Riau scores high on ANC in general, tetanus vaccination is very low and an important part of ANC. It is insufficient to rely only on ANC numbers
Ob-Gyns provide the most comprehensive services but reach only a limited population.
77
Antenatal Care Services by Type of Assistance in West Java (DHS 2007)
World Bank. 2010. “…and then she died..”. Indonesia Maternal Health Assessment.
Four areas for priority action to improve the health status of Indonesian mothers: Being implemented in ongoing pilots.
1. Improving coordination between public and private sector services at provincial and district levels
2. Strengthening coordination between community-based services and hospital services
3.Reducing financial barriers to utilization of maternal health services
4. Improving clinical skills and quality assurance
Increase research into near miss and maternal death for better understanding of the local contributing factors. Use this analysis to determine whether factors such as access to SHI, ANC, and place of delivery had an impact on outcomes
• Improve vital statistics registration, particularly for deaths among women of reproductive age
• Address the unmet need for access to emergency obstetric care among the large majority of the female population
• Conduct a hospital assessment for maternal health to identify barriers to care within the facility context
• Review the social insurance coverage amounts to expand what is reimbursed and to cover the true cost of having a delivery with a skilled provider.
• Review reimbursement mechanisms in the case of referral upwards to a hospital for complications.
• Improve the quality of the skilled provider, particularly the Bidan di Desa by building on existing initiatives (such as Bidan Delima) and linking quality of care to accreditation and certification.
• Look at the implementation of the comprehensive emergency obstetric services to find areas of improvement.
World Bank. 2010. Presentation on “…and then she died..”. Indonesia Maternal Health Assessment.
78
I M PA C T S T O D AT E :C o v e r a g e h a s e ff e c t i v e l y b e e n i n c r e a s e d a n d a n e s t i m a t e d o n e - t h i r d o f t h e p o p u l a t i o n i s c u r r e n t l y b e i n g c o v e r e d , a c c o r d i n g t o o ff i c i a l d a t a ( S u s e n a s s u r v e y d a t a i n d i c a t e s l o w e r c o v e r a g e r a t e s ) .Fo r t y - t h r e e p e r c e n t o f t h o s e c o v e r e d a r e p o o r a n d n e a r - p o o r h o u s e h o l d s .U t i l i z a t i o n o f h e a l t h s e r v i c e s a m o n g J a m k e s m a s b e n e fi c i a r i e s h a s i n c r e a s e d , e s p e c i a l l y f o r i n p a t i e n t s e r v i c e s .J a m k e s m a s h a s a p r o t e c t i v e e ff e c t o n t h e O O P h e a l t h e x p e n d i t u r e s o f t h e p o o r a n d n e a r - p o o r ; t h o s e w i t h J a m k e s m a s c o v e r a g e h a v e l o w e r O O P p a y m e n t s ( a m e a s u r e o f fi n a n c i a l p r o t e c t i o n ) a n d J a m k e s m a s b e n e fi c i a r i e s h a v e a l o w e r i n c i d e n c e o f c a t a s t r o p h i c m e d i c a l e x p e n d i t u r e s w h e n c o m p a r e d w i t h t h o s e w i t h n o i n s u r a n c e o r t h o s e w i t h o t h e r f o r m s o f i n s u r a n c e .G e o g r a p h i c a n a l y s i s s h o w s s i g n i fi c a n t i n c r e a s e s i n i n p a t i e n t u t i l i z a t i o n i n t h e p o o r e s t p r o v i n c e s ( N T T, Pa p u a , M a l u k u ) .
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Focus on JamkesmasUpdate in March 2011
I n v e s t i n g i n I n d o n e s i a ’ s H e a l t h : C h a l l e n g e s a n d O p p o r t u n i t i e s f o r F u t u r e P u b l i c S p e n d i n g . H e a l t h P u b l i c E x p e n d i t u r e R e v i e w – J u n e 2 0 0 8 I n d o n e s i a ’ s D o c t o r s , M i d w i v e s a n d N u r s e s : C u r r e n t S t o c k , I n c r e a s i n g N e e d s , F u t u r e C h a l l e n g e s a n d O p t i o n s . H e a l t h H u m a n R e s o u r c e s R e v i e w – J a n u a r y 2 0 0 9 G i v i n g M o r e We i g h t t o H e a l t h : A s s e s s i n g F i s c a l S p a c e f o r H e a l t h i n I n d o n e s i a – J a n u a r y 2 0 0 9 H e a l t h F i n a n c i n g i n I n d o n e s i a : a R e f o r m R o a d M a p – J u n e 2 0 0 9 N e w I n s i g h t s i n t o t h e P r o v i s i o n o f H e a l t h S e r v i c e s i n I n d o n e s i a : a H e a l t h Wo r k Fo r c e S t u d y – O c t o b e r 2 0 0 9 ‘ a n d t h e n s h e d i e d ’ : I n d o n e s i a M a t e r n a l H e a l t h A s s e s s m e n t – D e c e m b e r 2 0 0 9
Annex: World Bank Studies for the HSR
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Forthcoming:
Actuar ia l Cost ing of Universa l Heal th Insurance Coverage in Indones ia : Op t i ons and Pre l im inary Resu l t s – J anuary 2011 Enhancing Heal th Equi ty and F inanc ia l Protect ion in Indones ia : How We l l Does J amkesmas do? J amkesmas Rev i ew Paper - March 2011
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Annex: Forthcoming World Bank Studies
Pharmaceu t i ca l s : Why Re form i s Needed – March 2009 Acce l e ra t i ng I mprovement i n Mate rna l Hea l th : Why Re form i s Needed – June 2010 F i nanc ing Un i ve r sa l Coverage : Assess ing F i sca l Space i n Indones i a – Ju l y 2010 Ach i ev ing Un i ve r sa l Coverage : D iff eren t S tages o f Harmon i za t i on o f I mp lement ing Hea l th I nsurance In fo rmat i on Sys tems – Augus t 2010Forthcoming: Hea l th Pro fess i ona l Educa t i on i n I ndones i a : Why Re form i s NeededMaterna l Hea l th Mee ts Hea l th F inanc ing
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Annex: World Bank Policy Notes Series